0107-089 (PLBG)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
745159 C4 6-14;C
Date ". i Signature of Contractors" --
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) I,'as owner of the property, or my employees with wages as their sole
compensation, will do the work, and the structure is not intended or offered for
sale (Sec. 7044, Business & Professionals Code).
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct'1he project (Sec. 7044, Business & Professionals
Code).
() I am exempt under Section , B&P.C. for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
( ) I have and will maintain a certificate of consent to self -insure for workers'
compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
( ) I have and will maintain workers' compensation insurance, as required by
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued. My4orkers' compensation insurance carrier & policy no. are:
Carrier Policy No.
13TA`i E, F") ).tom?3-a
(This section need not be completed if the permit valuation is for $100.00 or less).
( ) I certify that in the performance of the work for which this permit.is issued,
I•shall not employ any person in any manner so as to become subject to the
workers' compensation laws of California, and agree that if I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.
Dater r Applicant—
Warning:
pplicant Warning: Failure to secure Workers,Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of'compensation, damages as provided for in Section 3706
of,the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for; a permit subject to the conditions ,and restrictions set forth on his
application.
1. Each person upon whose behalf this,application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of.this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives' of this :City to enter upon
the above-mentioned property for inspection purposes
Signature (Owner/Agent)` f�LY ^� Date�F'u;- r
c BUILDING PERMIT PERMITk
DATE' VALUATION LOT ° �'IC}L TRACT
JOB SITE.' �
ADDRESS'
APN
'1
i 79—OW 90MOOF, ROAD
'•
OWNER
CONTRACTOR/DESIGNER/EN (NEER
3� t Af 'Zvi
V", NO R"WER. SERVICE
7�pp'-�%8yf^��?'�r4�3R►.�.`�?'��YELANE
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q ry
T,.nL''A QUI -ITA CA 922 3
�R)4�Oy35
J,'Pii.Ml, F-9MT CA 92461
(76(k)346-2793 MIN 342.
USE OF PERMIT
w;�"e�ffi fii.f? vlJ;irp� it: �a�dO1dA9L7�T .-
VALUATION � 21650.00 LIS
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:t?'�' ''�,' T,") C09;9'' [' isONSINITCfv'RON
USDA()
FMMITE STAM. ARY
PLUNIDWO RE
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NI
JUL 10 2001 j
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CITY OF LA WNTF
Flf;AKE DEPT
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RECEIPT
DATE
DATE FINALED �"
INSPECTOR
,ByY�
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
OX to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water, Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
Gas Piping
Gas Test
Pool Cover
Encapsulation
Appliances
Final
COMMENTS:
Final_$1
Utility Notice (Gas) i0i 17
ELECTRICAL APPROVALS .
Temp. Power Pole
Underground Conduit
'Rough Wiring
Low Voltage Wiring
t!x ures
Main Service
'Sub Panels
Exterior Receptacles
G. F.I.
Smoke Detectors
Temp. Use of Power i.
Final
U.ti_lity Notice (Perm)
COACHELLA VALLEY WATER DISTRICT
CASH RECEIPT DETAIL
f.Received
:z I C .e.(I
Address: �,Y f , C
Lot(s)
Service Address
0 Meter(s)
0 Service(s)
L
0 Backflow(s)
0 House Lateral(s)
0 Detector Check(s)
is 0 Meter Surcharge
i9r'sanitation Capacity Charge
�5 15
0 W.S.B.F.C.
0 Temporary Construction Meter
f.
0 Turn on Charge
0 Uncollected Account - Name
0 Inspection Fee Tract -
Fee -
0 Plan Check Fees Water /'Sewer -
Tract -
f
0 Bond Payment - A.D. - —Bond
Assmt.
1.
0 Customer Deposit
0 Other
tRemarks:
—9 -Copy to:
%TO
TOTAL
" , TOT(
{AL
Cash
Water Service,'
X
Check r r.
Money
Cashier
...... . ... ......
EC SEWER SERVICE, INC.
dba ECONO SEWER SERVICES
P.O. BOX 192 • PALM DESERT, CA 92261
(760) 346-2793 (760) 328-7760
JON MORE ORDER
14896
FAX (760) 347-4978
DATE OF ORDER
SERVICE CODE
PHONE I
TEJCLD
HELPER
STARTING DATE/ 1
BILL TO
TYPE OF WORK
❑ CLEAN DRAINS
❑ OTHER
TANK
❑ GREASE TRAP
AGE PIT
ADDRESS
i�TIC
CITY.
JoErNAME AND LOCATION
ADDITIONAL WORK NEEDED:
TANK SIZE:
PAYMENT TERMS NET 10 DAYS FROM DATE OF SERVICE 1'/2% PER MONTH CHARGE AFTER 30 DAYS.
DESCRIPTION„OF WORK: _ .
'
CONDITION OF TANK BEFORE SERVICE
_ Good_
- — - _ Trash & Garbage _ _ Excessive soap
i
Overflowing _ Sand
PorBlockage
Repairs Needed
ry PooOdor
!R.
TOTAL LABOR
_ More frequent service needed
'
TOTAL PUMP
DISPOSAL FEE
TOTAL LABOR
PLEASE PAY FROM THIS INVOICE. NO STATEMENT WILL BE MAILED.
TOTAL MATERIALS
DATE COMPLETED
WORK ORDERED BY
TOTAL AMOUNT
$
Signature
❑ No one home ❑ Total amount due
for above work: or
I hereby acknowledge the satisfactory completion
of the above described work.
Ej Total billing to
be mailed after
completion
of work